Spinal cord compression (non-traumatic)

Background

  • Compression of the spinal cord from non-traumatic etiology
  • A neurologic emergency — neurologic deficits may become permanent if not promptly treated
  • Most common cause: metastatic cancer (malignant epidural spinal cord compression) — affects 5-10% of cancer patients[1]
  • Other causes: Epidural abscess, epidural hematoma, disc herniation, degenerative stenosis
  • Thoracic spine is the most commonly affected level in malignancy (60%)

Etiology

  • Malignancy: lung, breast, prostate, renal cell, lymphoma, multiple myeloma
  • Epidural abscess: hematogenous spread or direct extension; risk factors include IVDU, immunosuppression, recent spinal procedure
  • Epidural hematoma: anticoagulation, post-procedural, coagulopathy
  • Disc herniation: central disc causing cord compression (thoracic or cervical)
  • Degenerative spinal stenosis with myelopathy
  • Vertebral compression fracture (osteoporotic or pathologic)

Clinical Features

  • Back pain (present in >90% of malignant cases) — often worse at night, worse supine
  • Progressive weakness (upper motor neuron signs below level of compression)
    • Hyperreflexia, spasticity, positive Babinski sign
    • May present as difficulty walking or frequent falls
  • Sensory level — band-like numbness at level of compression
  • Bowel/bladder dysfunction — urinary retention, incontinence (late finding; poor prognostic sign)
  • Fever + back pain + neurologic deficit = epidural abscess until proven otherwise
  • Vertebral tenderness to palpation

Differential Diagnosis

Evaluation

  • MRI of entire spine with and without gadolinium — imaging of choice[2]
    • Entire spine because multifocal disease is common with malignancy
    • Emergent MRI — do not delay
    • CT myelography if MRI unavailable or contraindicated
  • Labs
    • If infection suspected: CBC, ESR, CRP, blood cultures (ESR >20 has high sensitivity for epidural abscess)
    • If malignancy: LDH, calcium, alkaline phosphatase
    • Coagulation studies if epidural hematoma suspected
  • X-rays of spine: may show vertebral body destruction, but cannot rule out cord compression

Management

Malignant Cord Compression

  • Dexamethasone — give immediately when suspected (before imaging if high suspicion)
    • 10 mg IV bolus, then 4 mg IV/PO q6h[3]
  • Emergent radiation oncology and/or neurosurgery/spine surgery consultation
  • Surgical decompression + radiation therapy superior to radiation alone for selected patients
  • Pain management: opioids, consider PCA

Epidural Abscess

  • Broad-spectrum IV antibiotics: Vancomycin + Ceftriaxone (or Cefepime)
  • Blood cultures before antibiotics (if does not delay treatment)
  • Emergent neurosurgical consultation for drainage
  • See Epidural abscess for detailed management

Epidural Hematoma

  • Reverse anticoagulation immediately
  • Emergent neurosurgical consultation for possible decompression

Disposition

  • Admit all cases of spinal cord compression
  • New neurologic deficits require emergent evaluation and treatment
  • Ambulatory status at presentation is the strongest predictor of outcome

See Also

References

  1. ↑ Loblaw DA, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression. J Clin Oncol. 2005;23(9):2028-2037. PMID 15774794.
  2. ↑ Quraishi NA, et al. Metastatic spinal cord compression. BMJ. 2015;350:h2539. PMID 26037491.
  3. ↑ George R, et al. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2015;(9):CD006716. PMID 26337716.
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